Summary Report for FSPSAs Ending During the Report Period Center: 03
This report shows the total number of units/fees for FSPSAs ending during the report period.
(i.e., end date of service authorization occurs during the report period). This report does not
represent all FSPSAs that overlap the report period. Note that service authorization periods may
range from 1 to 12 months and may vary in intensity from child to child.
FSPSAs ending between: 10-01-21 and 12-31-21 Date of Report: 02-04-22 Page: 1
Child has a MEDICAID # Filter: Y
Eligibility Filter: Program Patients
With the filters selected there were 1046 FSPSA's found
Services Cpt Code Number of Number of Total Units Total Cost of Avg Fee
Children Records Authorized Auth Services Per Unit Auth
Service Coordination, Class # 01
SCONLY-SCONLY *SERVICE COORDINATION ONLY 36 36 18.027779 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 36 36 18.027779 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 17 22 16.288888 $790.0100 $48.5000
AUDE -V5090 DISPENSING FEE PER HEARING AID 1 1 0.235616 $27.0900 $114.9900
OCTH -97167 OT EVAL HIGH COMPLEXITY 28 31 16.424049 $838.4500 $51.0500
PSTH -97163 PT EVAL HIGH COMPLEXITY 37 43 17.794444 $908.4000 $51.0500
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 54 57 36.200990 $1848.0700 $51.0500
SPCH -92610 EVAL OF ORAL,PHARYNGEAL SWALLOWING 1 1 1.000000 $44.5500 $44.5500
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Subtotal (Total Children Is Unduplicated) 115 155 87.943987 $4456.5700 $50.6800
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 15 18 14.611034 $73055.0000 $4999.9900
CONIF -CONIF CONSULT, ITDS FACE TO FACE 24 28 41.988889 $2099.4500 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 77 83 85.490476 $4274.5200 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 50 53 49.799997 $2489.9900 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 113 131 123.919045 $6195.9400 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 306 346 1258.742868 $62937.1400 $50.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 1 2 12.190476 $609.5200 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 37 47 201.419049 $14389.3900 $71.4400
PHY -97110 PT SESSION BY LICENSED PT 52 65 253.466664 $18107.6400 $71.4400
SENS -V5050 IN EAR MONAURAL HEARING AID 1 1 0.235616 $53.7200 $227.9800
SENS -V5264 EARMOLD 1 1 0.235616 $4.2400 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 70 80 273.833339 $19562.6800 $71.4400
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Subtotal (Total Children Is Unduplicated) 475 855 2315.933069 $203779.2200 $87.9900
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Total 1046 2421.904835 $208235.7900 $85.9800
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Number of Children (Unduplicated) With at Least One Authorization 512